Atopic Dermatitis

Atopic Dermatitis

 

Rash.” Certainly, this is not a favorite chief complaint in the Ped ED, but unquestionably it is a common one. While there may be very few “rash emergencies,” there are several significant conditions to ponder (ex, Kawasaki, ITP, HUS) as well as less concerning ones (ex, Molluscum). Additionally, before you dismiss the condition as being “not an emergency,” consider that there may be some helpful advice that you can provide. Often, a few tactful reminders and tips can lend comfort. Let us consider the most recent update [Eichenfield, 2015] on the seemingly ubiquitous Atopic Dermatitis.

 

Atopic Dermatitis: Basics

  • In the US, estimated to affect ~12.5% of pediatric patients!
  • Diagnosis:
    • No lab test to make the diagnosis.
    • Combination of symptoms and findings:
      • Relapsing and/or Chronic Pruritic dermatitis
      • Distributed on face, neck, extensor surfaces as well as flexural folds.
      • Erythematous papules and patches
      • Dry skin (xerosis)
      • Excoriations
    • Generally, spares the groin and axilla
  • Consider other conditions that may mimic appearance:
    • Psoriasis
    • Ichthyoses
    • Erythroderma
    • Scabies
    • Seborrheic dermatitis
    • Contact dermatitis
    • Photosensitivity dermatitis
    • Immune deficiency disease
    • Cutaneous T-Cell lymphoma

 

Atopic Dermatitis: Severity

Generally speaking, these are not very distinct classifications and make intuitive sense, but are most useful in helping to determine appropriate care.

  • Mild
    • Involves less body surface area
    • Have less exacerbations
    • Has less itch
  • Moderate – Severe
    • Involves greater amount of body surface area
    • More persistent symptoms
    • More severe itch
    • Often require maintenance medications to help manage.
      • Like with persistent asthma, “controller” medications can be helpful to manage mod-severe atopic dermatitis.
      • Ex: Tacrolimus and/or Low-Medium potency topical corticosteroids used twice weekly.

 

Atopic Dermatitis: Routine Management

  • Basic skin care is integral in the management of atopic dermatitis.
  • These should be re-emphasized for all patients presenting with complaints consistent with atopic dermatitis. [Eichenfield, 2015]
    • Skin Hydration
      • Skin moisturizers used liberally and frequently even to uninvolved skin.
        • Lotions actually can be drying.
        • Favor ointments over lotions.
      • Using mild soaps and apply skin moisturizers when still damp (after bathing).
    • Antiseptic Measures
      • Dilute bleach baths twice weekly (more frequently for those with recurrent skin infections) can help decrease risk of skin infections and decrease atopic dermatitis severity. [Huang, 2011; Huang, 2009]
      • ~0.5 cup of sodium hypochlorite diluted in 40 gallons of water (1 full bath tub)
    • Trigger Avoidance
      • Trigger identification can be challenging, but is also very helpful (just like for any other atopic condition).
      • Some common triggers: soaps, wool and abrasive clothing, lotions, fragrances, tight fitting clothing, food allergens and extremes in temperatures/humidity.

 

Atopic Dermatitis: Acute Therapy

  • Topical corticosteroids
    • For patient’s with Mild Disease
      • Low potency corticosteroids twice daily for up to 3 days beyond improvement.
      • Apply only to area involved with flare.
      • Ex: Hydrocortisone ointment, dexamethasone cream
    • For patient’s with Mod-Severe Disease
      • Medium potency corticosteroids twice daily for up to 3 days beyond improvement.
        • Apply only to area involved with flare.
        • Ex: Triamcinolone ointment, Fluticasone ointment
      • Consider possible secondary skin infection as well.
  • Reinforce the need to continue with the Routine Skin Care above.
  • May refer to other educational resources, like nationaleczema.org.

 

References

Eichenfield LF1, Boguniewicz M2, Simpson EL3, Russell JJ4, Block JK5, Feldman SR6, Clark AR7, Tofte S8, Dunn JD9, Paller AS10. Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers. Pediatrics. 2015 Sep;136(3):554-65. PMID: 26240216. [PubMed] [Read by QxMD]

Nguyen TA1, Leonard SA2, Eichenfield LF3. An Update on Pediatric Atopic Dermatitis and Food Allergies. J Pediatr. 2015 Sep;167(3):752-6. PMID: 26118932. [PubMed] [Read by QxMD]
Sidbury R1, Tom WL2, Bergman JN3, Cooper KD4, Silverman RA5, Berger TG6, Chamlin SL7, Cohen DE8, Cordoro KM6, Davis DM9, Feldman SR10, Hanifin JM11, Krol A11, Margolis DJ12, Paller AS7, Schwarzenberger K13, Simpson EL11, Williams HC14, Elmets CA15, Block J16, Harrod CG17, Smith Begolka W18, Eichenfield LF2. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218-33. PMID: 25264237. [PubMed] [Read by QxMD]

Huang JT1, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. 2009 May;123(5):e808-14. PMID: 19403473. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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